Marjon Borgert

202 Chapter 9 to overcome existing barriers. The implementation strategies should be evidence-based and have a theoretical foundation. 33,34 However, given the uncertainty of the outcome of each implementation activity, cost and time investment should be taken into account. The additional costs of multifaceted implementation strategies should be weighed against the realistic chance of (regularly) achieving only small improvements. 31 As described in the Introduction section, we should realize that errors inevitably occur in hospitals. 35,36 Human errors are hardly ever caused in isolation by one person, but can occur due to underlying aws within the organizational system. 37 To protect patients against these human errors, the working environment, or so called ‘system’, needs to be redesigned. This can, for instance, be achieved by the simpli cation and standardization of processes, automation, standardization of equipment and functions, or by decreasing simple reliance on memory (Chapters 2 and 7). 27,38,39 With these methods, care processes can be optimized to improve the reliability of care. Improving reliability means that clinical procedures need to be applied reliably, such as compliance with hand hygiene or timely administration of antibiotics for septic patients. 40 The use of care bundles or early warning score systems to detect clinical deterioration, are also useful strategies to improve the reliability of care processes (Chapters 2 and 7). Such quality improvement strategies are necessary and widely applied on hospital wards. However, they are never the complete solution for achieving improvements. These interventions could for instance be complemented by strategies to enhance the safety culture itself. The concept of a ‘safety culture’ has become an important one for hospitals striving to improve patient safety. 41 Safety culture re ects the attitude, values, perceptions and beliefs of leaders andhealth careproviders towards taking risks, following rules, speaking up about safety and the values of risk management and safety. 42,43 Safety culture can vary signi cantly between di erent wards and di erent groups, and each group or discipline has its own culture and habits. 27 What are known as ‘high safety cultures’ are more willing to change behaviour and are associated with improved reliability of care. 44 Pronovost et al. showed that promoting the safety culture, in combination with the implementation of a central line bundle, resulted in large improvements in infection reductions. 44 But, improving the safety culture is a real challenge at every organizational level. This can only be achieved when leaders are visibly willing to change and when they encourage health care providers to openly talk about and share safety issues. If such a safety culture is not achieved, it can lead to an unwillingness to report adverse or other unsafe events. Professionals may fear disciplinary measures, or believe that reporting will not result in change. 41-43 A safety culture needs to be present at all levels of the organization in order to improve quality of care.